Estimating Risk of Postsurgical General and Geriatric Complications Using the VESPA Preoperative Tool

Prevalence of preoperative depression and adverse outcomes in older patients undergoing elective surgery: A systematic review and meta-analysis

STUDY OBJECTIVE

Depression is a common cause of long-lasting disability and preoperative mental health state that has important implications for optimizing recovery in the perioperative period. In older elective surgical patients, the prevalence of preoperative depression and associated adverse pre- and postoperative outcomes are unknown. This systematic review and meta-analysis aimed to determine the prevalence of preoperative depression and the associated adverse outcomes in the older surgical population.

DESIGN

Systematic review and meta-analysis.

SETTING

MEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase/Embase Classic, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews, ClinicalTrials.Gov, the WHO ICTRP (International Clinical Trials Registry Platform) for relevant articles from 2000 to present.

PATIENTS

Patients aged ≥65 years old undergoing non-cardiac elective surgery with preoperative depression assessed by tools validated in older adults. These validated tools include the Geriatric Depression Scale (GDS), Hospital Depression and Anxiety Scale (HADS), Beck Depression Inventory-II (BDI), Patient Health Questionnaire-9 (PHQ-9), and the Centre for Epidemiological Studies Depression Scale (CESD).

INTERVENTIONS

Preoperative assessment.

MEASUREMENT

The primary outcome was the prevalence of preoperative depression. Additional outcomes included preoperative cognitive impairment, and postoperative outcomes such as delirium, functional decline, discharge disposition, readmission, length of stay, and postoperative complications.

MAIN RESULTS

Thirteen studies (n = 2824) were included. Preoperative depression was most assessed using the Geriatric Depression Scale-15 (GDS-15) (n = 12). The overall prevalence of preoperative depression was 23% (95% CI: 15%, 30%). Within non-cancer non-cardiac mixed surgery, the pooled prevalence was 19% (95% CI: 11%, 27%). The prevalence in orthopedic surgery was 17% (95% CI: 9%, 24%). In spine surgery, the prevalence was higher at 46% (95% CI: 28%, 64%). Meta-analysis showed that preoperative depression was associated with a two-fold increased risk of postoperative delirium than those without depression (32% vs 23%, OR: 2.25; 95% CI: 1.67, 3.03; I2: 0%; P ≤0.00001).

CONCLUSIONS

The overall prevalence of older surgical patients who suffered from depression was 23%. Preoperative depression was associated with a two-fold higher risk of postoperative delirium. Further work is needed to determine the need for depression screening and treatment preoperatively.

Adjusting the Split: Examining Complications After Emergency Exploratory Laparotomy in Older Adults

INTRODUCTION

Older adults experience higher rates of complications after an emergency exploratory laparotomy (EEL). To better understand the shift to an aging population in the United States, identifying how age may influence these complications in older patients is important. The current standard age category for older adult patients is ≥65. We analyzed postlaparotomy complications using a lower age split.

METHODS

A retrospective analysis was done on patients who required an EEL from October 2015 to December 2019 at an academic medical center. Patient demographics and hospital course variables were collected. Differences in complications in patients aged ≥/<55 y and ≥/<65 y were measured using univariate and multivariable analyses.

RESULTS

A total of 481 patients were reviewed. Both patient groups of ≥55 and ≥65 were typically male, White, had 3+ comorbidities, Medicare insurance, were retired, and presented in extremis to the emergency department. Patients aged ≥55 y had significant rates of pulmonary complications and inpatient mortality (odds ratio 2.2, 2.7, respectively). Patients aged ≥65 y had significant rates of genitourinary and cardiac complications (odds ratio 2.3, 1.8, respectively).

CONCLUSIONS

Patients aged ≥55 y undergoing EEL had higher odds of experiencing pulmonary complications and death during their index hospitalizations, which was not present with the standard ≥/<65-y-old patient analysis. Those aged ≥65 y experienced index genitourinary and cardiac complications. The ≥/<55 age split has a unique set of complications that should be considered. Given the increased odds of inpatient mortality and types of complications in patients aged ≥55 y, the current age split for older adults should be reconsidered.

Frailty as a predictor of adverse outcomes in head and neck reconstruction: A systematic review

BACKGROUND

Frailty has been shown to adversely impact outcomes in a number of surgical disciplines. In head and neck reconstructive surgery, frailty may represent a significant risk factor in predicting post-operative outcomes due to the common characteristics of the patient population undergoing these procedures.

OBJECTIVES

To summarize the available evidence about frailty as a predictor of post-operative complications, length of hospital stay and quality of life in patients undergoing head and neck reconstructive surgery.

STUDY DESIGN

Systematic Review.

METHODS

The study protocol was registered with PROSPERO, registration CRD42022302899. Methodology was in keeping with the PRISMA Guidelines for Systematic Reviews. MEDLINE, SCOPUS, EMBASE, Web of Science and CENTRAL were the databases searched. Qualitative synthesis of the included studies was carried out, and quality assessment was performed.

RESULTS

Nine studies that reported data on 10,457 patients undergoing reconstruction of the head and neck were included in the review. A number of different tools were used to assess frailty, with the modified frailty index being the most frequently used. In total, 8 studies reported increased rates of complications in patients with increased levels of frailty, irrespective of the frailty tool used, with varied levels of statistical significance across the studies.

CONCLUSION

An association is observed between increased rates of perioperative complications and increased levels of frailty in patients undergoing head and neck reconstruction. Frailty tools may represent a useful method to risk stratify patients undergoing reconstructive head and neck surgery.

Associations of an eye-tracking task and pupillary metrics with age and ASA physical status score in a preoperative cohort

Advanced age, American Society of Anesthesiologists physical status (ASA) classification and the presence of cognitive impairment are associated with an elevated risk of postoperative morbidity and mortality. The visual paired comparison (VPC) task, which relies on recognition of novel images, examines declarative memory. VPC scores have demonstrated the ability to detect mild cognitive impairment and track progression of neurodegenerative disease. Quantitative pupillometry may have similar value. We evaluate for associations between these variables of interest and the feasibility of performing these tests in the preoperative clinic. Prospective data from 199 patients seen in the preoperative clinic at a tertiary academic center were analyzed. A 5 min VPC task (Neurotrack Technologies, Inc, Redwood City, CA) was administered during their scheduled preoperative clinic visit. Pupillary light reflexes were measured at the same visit (PLR-3000™, Neuroptics Corp, Irvine, California).Thirty-four percent of patients were categorized as ASA 2 and 58% as ASA 3. Median age was 57 (IQR: 44-69). Associations were demonstrated between age and ASA physical status (Mann-Whitney U Test, p < 0.0001), maximum pupil size (Spearman Rank Correlation, r = - 0.40, p < 0.0001), and maximum constriction velocity (Spearman Rank Correlation, r = - 0.39, p < 0.0001). Our data also revealed an association between VPC score and age (Spearman Rank Correlation, p = 0.0016, r = - 0.21) but not ASA score (Kruskal-Wallis Test, p = 0.14). When compared to a nonsurgical cohort with no history of memory impairment, our population scored worse on the VPC task (Mann-Whitney U Test, p = 0.0002). A preoperative 5 min VPC task and pupillometry are feasible tests in the preoperative setting and may provide a valuable window into an individual's cognition prior to elective surgery.

Preoperative physical performance predicts pulmonary complications after coronary artery bypass grafting: a prospective study

The purpose of this study is to evaluate the relationship between preoperative physical performance (grip strength, gait speed, timed up and go) and postoperative pulmonary complications (PPCs) in patients who have undergone coronary artery bypass grafting (CABG). From September 2019 to August 2021, a total of 497 CABG patients who met the inclusion criteria of this study were examined for grip strength, 4-m gait speed, and timed up and go (TUG) before CABG surgery. Among them, 438 were included in the final analysis. PPCs were classified according to the operational definition of Kroenke et al. and patients with clinically significant PPCs were included in the data analysis. Logistic regression was utilised to analyse the relationship between physical performance and clinically significant PPCs. Besides, the receiver operating characteristic (ROC) curve was applied to analyse the predictive effect of grip strength, gait speed, and TUG on clinically significant PPCs after the CABG procedure. In total, 103 (23.5%) patients developed clinically significant PPCs after CABG. After making adjustments for the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and confounding factors, we established that low grip/weight (OR 0.510; 95% CI 0.363–0.715), slow gait speed (OR 0.619; 95% CI 0.517–0.741), and prolonged TUG (OR 1.617; 95% CI 1.379–1.895) were all independently correlated with clinically significant PPCs after CABG. The ROC curve analysis indicated that the area under the ROC curve of the integrated model of the three indicators (AUC 0.792 vs. 0.682, 0.754, 0.765) was larger than that of the model with a single indicator. Besides the predictive effect of the integrated model was superior to the models using grip/weight, gait speed, or TUG alone. Physical performance, including grip/weight, gait speed, and TUG, is a predictive factor for PPCs in CABG patients, and can be used in preoperative evaluations to and help improve the management of high-risk patients.

Behaviours of older adults and caregivers preparing for elective surgery: a virtually conducted mixed-methods research protocol to improve surgical outcomes

INTRODUCTION

Older adults (age ≥65 years) are pursuing increasingly complex, elective surgeries; and, are at higher risk for intraoperative and postoperative complications. Patients and their caregivers frequently struggle with the postoperative recovery process at home, which may contribute to complications. We aim to identify opportunities to intervene during the preoperative period to improve postoperative outcomes by understanding the preparatory behaviours of older adults and their caregivers before a complex, elective surgery.

METHODS AND ANALYSIS

As a result of the COVID-19 pandemic, we will conduct this study via telephone and videoconferencing. Using a multiphase mixed-methods research design, we will collect data on 10-15 patient-caregiver dyads from a pool of older adults (across a spectrum of cognitive abilities) scheduled for an elective colorectal surgery between 1 July 2020 and 30 May 2021. We will collect quantitative and qualitative data before (T1, T2) and after (T3, T4) surgery. Preoperatively, participants will each complete a cognitive assessment and a semi-structured qualitative interview that focuses on their preparatory behaviours (T1). They will then answer questionnaires about mood, self-efficacy and home environment (T2). Three weeks following hospital discharge, participants will complete another qualitative interview focusing on a comparison of preoperative and postoperative preparedness (T3). Researchers will also collect information about the patient's medical conditions, the postoperative complications and healthcare utilisation from the patient's chart 30 days following discharge (T4). We will code and conduct thematic analysis of the qualitative data to identify salient themes. Quantitative data will be analysed using basic descriptive statistics to characterise the participants. We will integrate the qualitative and quantitative findings using results from the quantitative scales to group participants and with use of joint display analysis.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the University of Michigan IRB. Study findings will be disseminated through peer-reviewed journals and presentations at conferences.

The Correlation Between Case Total Work Relative Value Unit, Operative Stress, and Patient Frailty: Retrospective Cohort Study

OBJECTIVE

Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions.

SUMMARY OF BACKGROUND DATA

Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity.

METHODS

Using National and Veterans Affairs Surgical Quality Improvement Programs (2015-2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score).

RESULTS

Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [ρs = 0.587 (95% confidence interval, 0.586-0.587)], but negligible with frailty ρ = 0.177 (95% confidence interval, 0.176-0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases.

CONCLUSIONS

Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients.

Understanding the Health Characteristics and Treatment Choices of Older Men with Stress Urinary Incontinence

OBJECTIVE

To describe the health characteristics and current treatment choices of male stress urinary incontinence (mSUI) patients to inform patient-centered decision-making.

METHODS

We identified a cohort of mSUI patients aged ≥65 at UCSF and San Francisco VA. Using retrospective chart review and telephone interviews, we ascertained demographics, incontinence characteristics, Charlson Comorbidity Index (score ≥ 4 indicates significant morbidity), frailty with Timed Up and Go (TUG) test, functional dependence with activities of daily living (ADL), calculated life expectancy, and assessed mental health and quality of life (QOL). Bivariate analysis evaluated associations between subject characteristics and ultimate treatment type (conservative vs surgery; sling vs sphincter). Logistic multivariable models evaluating treatment choice were also constructed.

RESULTS

The 130 participants had a mean age of 75 and a mean incontinence score of 14.2 representing moderately bothersome incontinence. Nearly 80% had significant morbidity, three-quarters had >50% 10-year mortality risk, 10% needed help with 1 + ADL and 22% had a TUG >10 seconds indicating frailty. The mean physical and mental QOL scores were similar to the general population. Anxiety and depression were reported by 3.9% and 10%. In univariate and multivariable analysis, only incontinence characteristics were associated with conservative vs surgical treatment choice (P < .01).

CONCLUSION

Multi-morbidity, functional dependence, frailty, and limited life expectancy are common among older men with mSUI, yet current treatment choices appear to be driven by incontinence characteristics. As such, mSUI surgery should be considered among men across the spectrum of health and life expectancy.

Assessment of Preoperative Functional Status Prior to Major Head and Neck Surgery: A Pilot Study

OBJECTIVE

To demonstrate feasibility of a recently developed preoperative assessment tool, the Vulnerable Elders Surgical Pathways and Outcomes Analysis (VESPA), to characterize the baseline functional status of patients undergoing major head and neck surgery and to examine the relationship between preoperative functional status and postoperative outcomes.

STUDY DESIGN

Case series with planned data collection.

SETTING

Two tertiary care academic hospitals.

METHODS

The VESPA was administered prospectively in the preoperative setting. Data on patient demographics, ablative and reconstructive procedures, and outcomes including total length of stay, discharge disposition, delay in discharge, or complex discharge planning (delay or change in disposition) were collected via retrospective chart review. VESPA scores were calculated and risk categories were used to estimate risk of adverse postoperative outcomes using multivariate logistic regression for categorical outcomes and linear regression for continuous variables.

RESULTS

Fifty-eight patients met study inclusion criteria. The mean (SD) age was 66.4 (11.9) years, and 58.4% of patients were male. Nearly one-fourth described preoperative difficulty in either a basic or instrumental activity of daily living, and 17% were classified as low functional status (ie, high risk) according to the VESPA. Low functional status did not independently predict length of stay but was associated with delayed discharge (odds ratio [OR], 5.0; 95% CI, 1.2-21.3; P = .030) and complex discharge planning (OR, 5.7; 95% CI, 1.34-24.2; P = .018).

CONCLUSION

The VESPA can identify major head and neck surgical patients with low preoperative functional status who may be at risk for delayed or complex discharge planning. These patients may benefit from enhanced preoperative counseling and more comprehensive discharge preparation.

Impact of Preoperative Social Frailty on Overall Survival and Cancer-Specific Survival among Older Patients with Gastrointestinal Cancer

OBJECTIVES

Frailty is a multidimensional syndrome. However, typical frailty scales used in oncology clinics assess physical impairment and/or malnutrition but do not consider the social domain. Our study aimed to clarify the relationship between preoperative social frailty and overall survival (OS) and cancer-specific survival (CSS) among older patients with gastrointestinal cancer.

DESIGN

This was a prospective cohort study.

SETTING AND PARTICIPANTS

This single-center study recruited 195 patients with gastrointestinal cancer scheduled for curative surgery and aged >60 years.

METHODS

The outcomes considered were the OS and CSS of surgery. Primary associated factors included frailty defined as a Geriatric 8 score ≤14; social frailty defined as 2 or more of the following-going out less frequently, rarely visiting friends, feeling unhelpful to friends or family, living alone, and not talking with someone daily, and combinations therein [no frailty without social frailty (-/-), frailty without social frailty (+/-), no frailty with social frailty (-/+), and frailty with social frailty (+/+)]. We used the Cox proportional hazards model and the Fine and Gray proportional subdistribution hazard model adjusting for confounding factors.

RESULTS

Of the 195 patients, 181 (mean age, 72.0 years) were included for analysis. The median follow-up time was 994 days. Social frailty (hazard ratio 3.10) and their combinations [6.35; frailty with social frailty (+/+) vs no frailty without social frailty (-/-)] were significant predictors of OS. Social frailty (subdistribution hazard ratio 3.23) and their combinations (7.57) were significant predictors of CSS.

CONCLUSIONS AND IMPLICATIONS

Preoperative social frailty is a predictor of OS and CSS in older patients with gastrointestinal cancer. Screening for social frailty, frailty, and their combinations in older patients with cancer is important.

Machine learning predicts unpredicted deaths with high accuracy following hepatopancreatic surgery

Background

Machine learning to predict morbidity and mortality-especially in a population traditionally considered low risk-has not been previously examined. We sought to characterize the incidence of death among patients with a low estimated morbidity and mortality risk based on the National Surgical Quality Improvement Program (NSQIP) estimated probability (EP), as well as develop a machine learning model to identify individuals at risk for "unpredicted death" (UD) among patients undergoing hepatopancreatic (HP) procedures.

Methods

The NSQIP database was used to identify patients who underwent elective HP surgery between 2012-2017. The risk of morbidity and mortality was stratified into three tiers (low, intermediate, or high estimated) using a k-means clustering method with bin sorting. A machine learning classification tree and multivariable regression analyses were used to predict 30-day mortality with a 10-fold cross validation. C statistics were used to compare model performance.

Results

Among 63,507 patients who underwent an HP procedure, median patient age was 63 (IQR: 54-71) years. Patients underwent either pancreatectomy (n=38,209, 60.2%) or hepatic resection (n=25,298, 39.8%). Patients were stratified into three tiers of predicted morbidity and mortality risk based on the NSQIP EP: low (n=36,923, 58.1%), intermediate (n=23,609, 37.2%) and high risk (n=2,975, 4.7%). Among 36,923 patients with low estimated risk of morbidity and mortality, 237 patients (0.6%) experienced a UD. According to the classification tree analysis, age was the most important factor to predict UD (importance 16.9) followed by preoperative albumin level (importance: 10.8), disseminated cancer (importance: 6.5), preoperative platelet count (importance: 6.5), and sex (importance 5.9). Among patients deemed to be low risk, the c-statistic for the machine learning derived prediction model was 0.807 compared with an AUC of only 0.662 for the NSQIP EP.

Conclusions

A prognostic model derived using machine learning methodology performed better than the NSQIP EP in predicting 30-day UD among low risk patients undergoing HP surgery.

Predicting treatment toxicity in older adults with cancer

PURPOSE OF REVIEW

To provide an overview of the recent advancements in predicting toxicity associated with cancer treatment in older patients.

RECENT FINDINGS

Various screening tools and validated risk calculators have been shown to help predict toxicity from surgery and chemotherapy. Radiation therapy has been more challenging to select the appropriate tool to reliably predict patients at risk for toxicity and noncompliance. Ongoing work on electronic geriatric assessment tools is showing promise in making comprehensive assessment more feasible.

SUMMARY

Selecting appropriate cancer therapy is particularly important in older patients, and validated tools have been developed to guide clinicians for surgery and chemotherapy; however, radiotherapy toxicity remains an area for further development, as does the uptake of existing tools into routine oncology practice.

Clinical and Neuroimaging Correlates of Post-Transplant Delirium

Delirium is common among adults undergoing hematopoietic stem cell transplantation (HCT), although the clinical and neuroimaging correlates of post-HCT delirium have not been adequately delineated. We therefore examined the frequency of delirium and neuroimaging correlates of post-transplant delirium in a retrospective cohort of 115 adults undergoing neuroimaging after allogeneic HCT. Delirium was established using previously validated methods for retrospective identification of chart-assessed postprocedural delirium. Chart reviews were independently conducted by a multidisciplinary team with expertise in HCT, psychiatry, and psychology on consecutive allogeneic HCT patients who underwent neuroimaging assessments and transplantation at a single center between January 2009 and December 2016. Neuroimaging markers of white matter damage and brain volume loss were also recorded. In total, 115 patients were included, ranging in age from 20 to 74 years (mean [SD] age, 49 [13]). Fifty-three patients (46%) developed post-HCT delirium. In an adjusted model, delirium incidence was associated with older age (odds ratio [OR], 1.92 [1.28, 2.87] per decade, P = .002), greater severity of white matter hyperintensities (OR, 1.95 [1.06, 3.57], P = .031), and conditioning intensity (OR, 6.37 [2.20, 18.45], P < .001) but was unrelated to cortical atrophy (P = .777). Delirium was associated with fewer hospital-free days (P = .023) but was not associated with overall survival (hazard ratio, 0.95 [0.56, 1.61], P = .844). Greater incidence of delirium following HCT was associated with greater age, microvascular burden, and conditioning intensity. Pre-HCT consideration of microvascular burden and other neuroimaging biomarkers of risk may be warranted.

Definition and assessment of frailty in older patients: the surgical, anaesthesiological and oncological perspective

The number of oncology, surgery and anaesthesia procedures in older patients has greatly increased in recent years due to ageing populations. Older patients are typically characterised by physical changes such as comorbidities, decline in physiological activities and cognitive impairment. All these factors, together with polypharmacological therapies, may substantially impact perioperative outcome, quality of recovery and, more in general, quality of life. A comprehensive multidisciplinary approach to perioperative care is thus needed. The assessment of frailty has a central role in the pre-operative evaluation of older patients and, with a multidisciplinary approach. The best surgical procedures and oncologic therapies can be accurately discussed in the pre- and post-operative periods. All clinicians involved in this scenario should be proactive in multidisciplinary care to achieve better outcomes.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

A novel geriatric assessment tool that predicts postoperative complications in older adults with cancer

INTRODUCTION

Comprehensive geriatric assessment prior to oncologic surgery can help predict surgical outcomes. We tested whether an abbreviated geriatric assessment tool, the Vulnerable Elderly Surgical Pathways and outcomes Assessment (VESPA), would predict post-operative complications among older adults undergoing oncologic surgery.

METHOD

From 2008 to 2011, geriatric assessments were completed using the VESPA tool for patients age ≥ 70 seen in a pre-operative clinic. The VESPA assessed functional status, mood, cognition, and mobility, and can be completed in <10 min. We selected the subset of patients who underwent oncologic surgery and evaluated the VESPA's ability to predict post-operative surgical complications, geriatric complications (e.g., delirium), length of stay, and geriatric post-discharge needs (e.g., new functional dependence).

RESULTS

A total of 476 patients who underwent oncologic surgery received the assessment using VESPA. Compared to patients with low VESPA scores (<9), patients with high VESPA scores (≥9) had longer length of stay (mean 6.6 vs. 2.0 days; p < .001), more geriatric complications (39.5% vs. 5.7%; p < .001), more surgical complications (29.5% vs. 11.8%; p < .001), and more likely to have post discharge needs (76.0% vs. 31.7%; p < .001). Using logistic regression, each additional point on the VESPA scale was also associated with increased probability of geriatric complications (OR = 1.3; 95% CI = 1.2-1.4), surgical complications (OR = 1.2; 95% CI = 1.1-1.2), and geriatric post-discharge needs (OR = 1.3; 95% CI = 1.2-1.3).

CONCLUSION

The VESPA identifies older patients with cancer who are at risk for postoperative surgical and geriatric complications as well as functional needs at hospital discharge.

A Preoperative Cognitive Screening Test Predicts Increased Length of Stay in a Frail Population: A Retrospective Case-Control Study

BACKGROUND

Frailty is associated with adverse perioperative outcomes including major morbidity, mortality, and increased length of stay. We sought to elucidate the role that a preoperatively assessed Mini-Cog can play in assessing the risk of adverse perioperative outcomes in a population at high risk of frailty.

METHODS

In this retrospective case-control study, patients who were >60 years of age, nonambulatory, or had >5 documented medications were preoperatively assessed for handgrip strength, walking speed, and Mini-Cog score. The Emory University Clinical Data Warehouse was then used to extract this information and other perioperative data elements and outcomes data.

RESULTS

Data were available for 1132 patients undergoing a wide variety of surgical procedures. For the subset of 747 patients with data for observed-to-expected length of stay, an abnormal Mini-Cog was associated with an increased odds of observed-to-expected >1 (odds ratio, 1.52; 95% CI, 1.05-2.19; P = .025). There was no association of abnormal Mini-Cog with intensive care unit length of stay >3 days (P = .182) discharge to home with self-care (P = .873) or risk of readmission (P = .104). Decreased baseline hemoglobin was associated with increased risk of 2 of the 4 outcomes studied.

CONCLUSIONS

In a high-risk pool of patients, Mini-Cog may not be sensitive enough to detect significant differences for most adverse outcomes. Further work is needed to assess whether cognitive screens with greater resolution are of value in this context and to compare tools for assessing overall frailty status.

Recommendations and Alerting for Delirium Alleviation in Real-Time (RADAR): Protocol for a pilot randomized controlled trial

Background: Delirium is a common and serious complication of major surgery for older adults. Postoperative social and behavioral support (e.g., early mobilization, mealtime assistance) may reduce the incidence and impact of delirium, and these efforts are possible with proactive patient-care programs. This pilot trial tests the hypothesis that a multicomponent decision support system, which sends automated alerts and recommendations to patient-care programs and family members for high-risk patients, will improve the postoperative environment for neurocognitive and clinical recovery. Methods: This will be a randomized, controlled, factorial pilot trial at a large academic medical center. High-risk, non-cardiac surgery patients (≥70 years old) will be recruited. Patients will be allocated to a usual care group (n=15), Hospital Elder Life Program (HELP)-based paging system (n=15), family-based paging system (n=15), or combined HELP- and family-based system (n=15). The primary outcome will be the presence of delirium, defined by positive long-form Confusion Assessment Method screening. Secondary outcomes will include additional HELP- and family-based performance metrics along with various neurocognitive and clinical recovery measures. Exploratory outcomes include the incidence of positive family-based delirium assessments post-discharge, 36-item Short Form Survey, PROMIS Cognitive Function Abilities Subset 4a, and 30-day readmission rates. Ethics and dissemination: This trial has received approval by the University of Michigan Medical Institutional Review Board (IRBMED). Dissemination plans include presentation at scientific conferences, publication in medical journals, and distribution via educational and news media. Registration: ClinicalTrials.gov Identifier NCT04007523, registered on 7/3/2019.

Recommendations and Alerting for Delirium Alleviation in Real-Time (RADAR): Protocol for a pilot randomized controlled trial

Background: Delirium is a common and serious complication of major surgery for older adults. Postoperative social and behavioral support (e.g., early mobilization, mealtime assistance) may reduce the incidence and impact of delirium, and these efforts are possible with proactive patient-care programs. This pilot trial tests the hypothesis that a multicomponent decision support system, which sends automated alerts and recommendations to patient-care programs and family members for high-risk patients, will improve the postoperative environment for neurocognitive and clinical recovery. Methods: This will be a randomized, controlled, factorial pilot trial at a large academic medical center. High-risk, non-cardiac surgery patients (≥70 years old) will be recruited. Patients will be allocated to a usual care group (n=15), Hospital Elder Life Program (HELP)-based paging system (n=15), family-based paging system (n=15), or combined HELP- and family-based system (n=15). The primary outcome will be the presence of delirium, defined by positive long-form Confusion Assessment Method screening. Secondary outcomes will include additional HELP- and family-based performance metrics along with various neurocognitive and clinical recovery measures. Exploratory outcomes include the incidence of positive family-based delirium assessments post-discharge, 36-item Short Form Survey, PROMIS Cognitive Function Abilities Subset 4a, and 30-day readmission rates. Ethics and dissemination: This trial has received approval by the University of Michigan Medical Institutional Review Board (IRBMED). Dissemination plans include presentation at scientific conferences, publication in medical journals, and distribution via educational and news media. Registration: ClinicalTrials.gov Identifier NCT04007523, registered on 7/3/2019.

Risk factors for in-brain local progression in elderly patients after resection of cerebral metastases

Intracranial metastases are the most frequent brain tumor with recurrence rates after treatment of around 40–60%. Age is still considered a determinant of treatment and prognosis in this pathology. Recent studies analyzing the impact of metastasectomy in elderly patients focused on reporting perioperative mortality and morbidity rates but not on the evaluation of oncological outcome parameters. Aim of this study is to determine risk factors for in-brain local recurrence after brain surgery in this sub-population. From October 2009 until September 2016 all patients aged 65 years and above with histopathologically confirmed metastasis after surgical resection were retrospectively studied. Clinical, radiological and perioperative information was collected and statistically analysed. Follow-up consisted of clinical and radiological assessment every 3-months following surgery. 78 patients were included, of these 50% were female (39 patients). Median age was 71 years (66–83). Early postoperative-MRI verified a complete surgical resection in 41 patients (52.6%) and showed a tumor-remnant in 15 patients (19.2%). In 22 patients the MRI result was inconclusive (28.2%). None of the patients experienced severe complications due to surgery. The median postoperative NIHSS was adequate 1 ± 1.4 (0–6), nonetheless, insignificantly improved in comparison to the preoperative NIHSS (p = 0.16). A total of 20 patients (25.6%) presented local recurrence. The only statistically significant factor for development of local in-brain recurrence after resection of cerebral metastases in patients above 65 years of age was a tumor-remnant in the early postoperative MRI (p = 0.00005). Median overall survival was 13 months. Local in-brain recurrence after surgical resection of a cerebral metastasis in patients above 65 years of age was 25.6%. In our analysis, tumor-remnant in early postoperative MRI is the only risk factor for local in-brain recurrence. Oncological parameters in the present cohort do not seem to differ from recent phase III studies with non-geriatric patients. Nevertheless, controlled studies on the impact of metastasectomy in elderly patients delivering high quality reliable data are required.

Frailty assessment: from clinical to radiological tools

Frailty is a syndrome of cumulative decline across multiple physiological systems, which predisposes vulnerable adults to adverse events. Assessing vulnerable patients can potentially lead to interventions that improve surgical outcomes. Anaesthesiologists who care for older patients can identify frailty to improve preoperative risk stratification and subsequent perioperative planning. Numerous clinical tools to diagnose frailty exist, but none has emerged as the standard tool to be used in clinical practice. Radiological modalities, such as computed tomography and ultrasonography, are widely performed before surgery, and are therefore available to be used opportunistically to objectively evaluate surrogate markers of frailty. This review presents the importance of frailty assessment by anaesthesiologists; lists common clinical tools that have been applied; and proposes that utilising radiological imaging as an objective surrogate measure of frailty is a novel, expanding approach for which anaesthesiologists can significantly contribute to broad implementation.

Unrealistic Postsurgical Expectation of Independence Predicts Complex Hospital Discharge

BACKGROUND

Careful discharge planning for older surgical patients can reduce length of stay, readmission, and cost. We hypothesized that patients who overestimate their self-care ability before surgery are more likely to have complex postoperative discharge planning.

MATERIALS AND METHODS

The Vulnerable Elders Surgical Pathways and Outcomes Assessment is a brief preoperative assessment that can identify older (age ≥70) patients with multidimensional geriatric risk, defined by all three of the following: (1) physical or cognitive impairment, (2) living alone, and (3) lack of handicap-accessible home. The Vulnerable Elders Surgical Pathways and Outcomes Assessment also asks a novel postoperative self-care ability question, whether patient can independently provide self-care for several hours after discharge. Classifying patients into four groups based on multidimensional geriatric risk (full versus none or partial) and the self-care ability question (yes or no), we hypothesized those with unrealistic postsurgical expectation of independence (UPSI) (both fully at risk and "yes" to self-care ability question) would be at the increased risk for complex discharge planning. Complex discharge planning was defined as prolonged stay because of nonmedical reasons or multiple changes in discharge plans.

RESULTS

In 382 hospitalizations of ≥2 d, 366 had a nonmissing answer to the self-care question; of those 5% had UPSI and 6.3% needed complex discharge planning. The UPSI group was independently associated with greater risk of complex discharge planning compared with the normal group (odds ratio = 4.3 [95% confidence interval, 1.1-16.1]).

CONCLUSIONS

Complex discharges were rare, but predictable by preoperative geriatric screening. Patients with UPSI should be targeted for postoperative care planning in advance of surgery.

Cancer Care Delivery Research: A Path to Improving the Quality of Oncologic Surgical Care

The goal of cancer care delivery research (CCDR) is to inform sustainable practice changes that will provide better clinical outcomes and patient experience guided by patient values. CCDR encompasses salient concepts from other well-established research approaches and spans the continuum of research from hypothesis generation to effectiveness studies to policy development. CCDR incorporates pertinent attributes, such as saliency to stakeholders, inclusion of diverse participants, and implementation into real-world settings. This article provides examples of CCDR studies, focusing specifically on how CCDR can improve the quality of oncologic surgical care.

Relationship between preoperative patient-reported outcomes and hospital length of stay: a prospective cohort study of general surgery patients in Vancouver, Canada

OBJECTIVES

As an aging population drives more demand for elective inpatient surgery, one approach to reducing length of stay is enhanced evaluation of patients' preoperative health status. The objective of this research was to determine whether patient-reported outcome measures collected preoperatively can identify patients at risk for longer lengths of stay.

METHODS

This study was based on a prospectively recruited cohort of patients who were scheduled for elective inpatient general surgery in Vancouver, Canada. All participants completed a number of patient-reported outcome measures preoperatively, including the EQ-5D for general health status, the Patient Health Questionnaire (PHQ-9) for depression, and the pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G), known as the PEG, for pain. Patient-reported outcome data were linked to hospital discharge summaries. Multivariate regression was performed to estimate risk of longer lengths of stay, adjusting for patient and clinical characteristics. The primary outcome was length of stay and its associated cost. Data collection took place between October 2012 and November 2016.

RESULTS

Participation among the population of 2307 eligible patients was 50.5%, providing 1165 participants. Preoperative patient-reported outcomes were not concordant with hospital reported diagnoses of depression or pain. Patients' preoperative depression and pain scores were independently positively associated with longer length of stay after adjusting for patient-level characteristics. Patients whose PHQ-9 score was 10, representing clinically significant depression, were estimated to have a 1.53 day longer hospitalization, which was associated with an estimated incremental hospital cost of $1667.

CONCLUSIONS

Preoperative self-reported assessment of depression and pain can assist with identifying patients at higher risk of longer lengths of stay. Patient's self-reported preoperative measures of depression and pain should be incorporated into patient pathways. They provide opportunities for improving management of general surgery patients and possibly play a role in aligning hospital funding with patients' needs.

Clinical outcomes in older surgical patients with mild cognitive impairment

INTRODUCTION

Older adults, including those with mild cognitive impairment (MCI), are increasingly undergoing surgery.

METHODS

Relative risks (RRs) of MCI alone or with delirium on adverse outcomes were estimated in an ongoing prospective, observational cohort study of 560 nondemented adults aged ≥70 years.

RESULTS

MCI (n = 61, 11%) was associated with increased RR of delirium (RR = 1.9, P < .001) and delirium severity (RR = 4.6, P < .001). Delirium alone (n = 107), but not MCI alone (n = 34), was associated with multiple adverse outcomes including more major postoperative complication(s) (RR = 2.5, P = .002) and longer length of stay (RR = 2.2, P < .001). Patients with concurrent MCI and delirium (n = 27) were more often discharged to a postacute facility (RR = 1.4, P < .001) and had synergistically increased risk for new impairments in cognitive functioning (RR = 3.6, P < .001).

DISCUSSION

MCI is associated with increased risk of delirium incidence and severity. Patients with delirium and MCI have synergistically elevated risk of developing new difficulties in cognitively demanding tasks.